In 1982, a colleague approached Dr. Douglas Ousterhout with a challenge. The colleague was a practitioner of what was then known as genital sex-reassignment surgery, and is now called genital gender-confirmation surgery. At the time, the procedure was popularly regarded as the defining one for transgender patients. The colleague had performed genital surgery on a patient some years earlier, and the patient, who subsequently got breast implants, now had the body she desired. But she remained troubled by the masculine traits in her face, particularly her brow ridge. She hated it, and wore bangs to cover it up, but despite her best efforts she thought that she still had a man’s face. The colleague asked Ousterhout, a highly regarded cranio-maxillofacial surgeon, if he could help.

Ousterhout had never thought much about the broad structural differences between masculine and feminine faces. When he was performing reconstructive surgery on a child whose bone plates had fused incorrectly, his aim was to give the patient’s brain room to develop; when fixing a cleft palate, his goal was to insure that the child could eat and breathe and speak. The finer distinctions of gender were of little concern. But, after being presented with his colleague’s surgical problem, Ousterhout went across town to the Arthur A. Dugoni School of Dentistry, which had a renowned collection of human skulls that had been gathered, mostly from autopsies, by an orthodontist. Ousterhout spent hours there, taking measurements of the head from infancy to adulthood—observing, for example, how a masculine jaw developed nubbins at the corners, squaring the face, and noting the more pointed quality of a feminine chin.

“Tomorrow’s going to go by in the blink of an eye, literally,” the text read. “You’ll get to fall asleep and wake up the way you were supposed to be born.” A more down-to-earth addendum followed: “Plus some swelling.”

Armed with this research, and with information from physical-anthropology textbooks, he operated on the trans patient. He did not reduce her brow ridge, which he considered to be within the bounds of feminine physiognomy, but instead added medical-grade plastic into the concavity above it, giving her a smoother, more rounded profile. The surgery, which took four hours, was aggressive. When it was done, the nurses joked darkly with the patient that the doctor must have punched her really hard. But, after the full recovery period of a month, the transformation was impressive. Minute changes in the brow—a matter of a millimetre or two—had brought about dramatic results. The patient felt that she looked pretty and feminine: like herself, or the self she wanted to be.

Word spread in the trans community of Ousterhout’s work, and a trickle of patients turned into a steady stream. He started attending conferences and gatherings for trans people, giving presentations and offering consultations. His patients invariably had means, because the procedure, unlike genital surgery, was considered cosmetic by insurers and therefore not covered by them. Most insurance companies still classify facial feminization, which can cost as much as sixty thousand dollars, as an elective surgery. A few insurance companies, such as Blue Cross Blue Shield of Massachusetts, now cover some facial-feminization procedures.

Over the years, Ousterhout added several elements to his repertoire. First, he began offering nose jobs, having realized that, when patients’ brows were altered, it threw their noses into new, and sometimes unflattering, relief. Many of his innovations were developed in response to patients’ requests. After an airline pilot whose forehead he had feminized complained about the size of her jaw, he devised a technique for reducing the lower jaw without damaging the sensitive bundle of nerves that extend to the chin. For those who wanted a smaller chin, Ousterhout developed a method of excising sometimes more than a centimetre of bone from the lower face.

The anthropologist Eric Plemons spent a year observing Ousterhout’s practice, and recently published a book, “The Look of a Woman: Facial Feminization and the Aims of Trans-Medicine.” He argues that Ousterhout not only honed a set of techniques; he also developed a theory of gender difference. Ousterhout came to believe that, for trans patients, the most meaningful surgical intervention they could undergo was not genital but facial surgery. Few people you meet see your genitals, but everyone sees your face, and instantly makes assumptions about your gender, based on a subconscious assessment of your features. (Trans men typically have an easier time signalling their gender: testosterone therapy induces the growth of a beard, or the development of male-pattern baldness, and though trans men are sometimes of smaller stature, a short man is hardly viewed as remarkable, in the way that a very tall woman can be.)

Ousterhout initially sought to bring his patients within the middle of the femininity range that he had established through his research into facial shapes. But as he became known as the leading authority in facial feminization—a field that was rapidly being populated by other surgeons—his surgical interventions became more extensive. He gradually came to believe that he should try to make his patients look not just like average women but like beautiful women. In part, this was to counterbalance common masculine traits that a trans patient cannot alter, such as the size of her hands. But Ousterhout’s decision also had the effect of upholding certain cultural assumptions about what is beautiful or feminine. As Plemons, who is trans, writes, “Feminine is a term in which biological femaleness and aesthetic desirability collapse.” At the very least, Ousterhout wished to enable his patients to open the door to the UPS guy in their sweatpants, without the armor of makeup or careful hair styling, and be perceived as female. But he also believed that he had the ability to give his patients a face that emulated a feminine ideal.

Not everyone in the trans community sees facial feminization as offering unalloyed benefits.